I represent a patient with working diagnosis of ‘drug induced psychosis’ and argued no nature or degree at MHT. In reasons the MHT accepts nature not met and agrees no symptoms at time of MHT except lack of insight into having had DIP.
I don’t think lack of insight should be counted as a symptom of mental disorder and am planning to appeal. The case of Smith equates degree with the ‘current manifestation’ of Mental disorder. Any views?
I’ve always thought of insight as relevant to nature (with its link to prognosis) but I’ve heard people link it with degree (as it often improves when symptoms do) – the whole thing is a bit like the emperor’s new clothes. Definitely appeal, partly for guidance, and partly (whether it’s part of nature or degree or both) because it doesn’t sound like enough to keep someone locked up.
Hi it sits with both I think both nature and degree
I assume you’re arguing that drug induced psychosis is not a mental disorder? The manifestation of the psychosis is the nature. However that’s only relevant in the rationale for detention if it’s recurring, hence the place of insight. I have seen a drug induced psychotic patient with a samurai sword believing people were demons after his soul or something. It would be hard to argue that in that psychotic state there is no established mental disorder. If it happens every time they take substances it becomes more complicated…
Maybe if you can separate the drug part from the psychosis component that could provide clarity to the MHT. It sounds like they are saying ‘lack of insight’ because they do not feel patient will control their drug habits after discharge.
For example. Show how the patient has not presented any symptoms of psychosis which is largely due to the patient not being on any drugs. This would show that they can manage on their own.
If they require further reassurance that patient has the capability to cope without taking the drug that induces their psychosis then show them any further reports from the lead nurse or social worker about how they have been during their detention.
You could even if patient is open to it - show that patient is willing to undertake drug addiction therapy and will be seeking support in that area once discharged back into the community to continue the progress they have made already during their stay - this in return could reassure the MHT that patient is actively seeking to remain as they are currently after discharge.
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When I see the word ‘Insight’ it’s often used as an ambiguous term to sway any patient from any appeals. You need to ultimately look at what the current presentation is with the patient. If there is other documentation from any other sources to support the patient being safe to return to within the community - then you must appeal.
Ignore the term ‘insight’ - look at the facts.
Thank you for all your interesting replies.
I agree mostly with you Jonathan although I still do not think that a lack of ‘insight’ is enough to establish degree in the absence of other symptoms of mental disorder. It can’t be right to detain someone who is not unwell merely because they don’t realise they ever have been…
I was not arguing that DIP is not a mental disorder I was arguing that it is only a mental disorder whilst the patient is symptomatic i.e whilst degree is still present. I agree that it is more complex if the patient persistently takes substances but I think that on a first presentation of any mental disorder it is difficult for the RA to argue that 'nature ’ is met as there is no history to establish the ‘previous response to treatment.’
I think you have missed the point somewhat Sarah. My client has had their tribunal and I am thinking of appealing the tribunal decision. This was a first presentation of DIP and the MHT agree with the RA that ‘nature’ was not met.The question of discharge turned on whether the patient was still showing symptoms of Mental Disorder.
I may appeal but the patient is likely to be discharged soon so it is probably academic.
I read all of your OP and subsequent replies. The issues are not simply academic.
The law being the law can do what it likes! Everybody believes that ex parte Smith defined and separated ‘nature’ and ‘degree’ as distinct concepts and so ‘everybody’ believes they are obliged to obey what they believe the law said - except me of course who believes that logic stands above the law because it is sourced from an inherent mathematics in the universe. And so in history attempts to make value of Pi (a mathematical constant) 2.0 instead of the usual much less than 2, failed! On that occasion legal logic in unison with the logic of the universe, prevailed.
So what does that mean? It means that reality cannot be changed by the law or anybody else - ‘nature’ and ‘degree’ may overlap.
But first - a DIP is a mental disorder - and I really cannot be distracted to debate any alternative opinions nationally.
Next, lack of insight is a fundamental concept that is part of many mental disorders: dementia, clinical depression and a basket of psychoses [not a complete list]. To debate that would be like arguing that Pi is 2.0.
There is a spectrum of levels of insight - none (zero), partial (some fraction), full (good or near complete).
Levels of insight are clinically strongly associated with severity of illness. It’s this basic: the most severely ill people tend to be the most insightless. ‘Tend’ means it is possible but of low probability that a very severely ill person may have complete insight. [Needs deep thought - and there are levels of ‘deep thought’ as well]
Some may interpret lack of insight as ‘nature’ and some may consider it ‘degree’ in the artificial and misunderstood ‘black and white’ they believe in. But as I am not so constrained, I can can logically conceptualise insight as both ‘nature’ and ‘degree’. How? If I have a ‘statistical patient’ who is floridly psychotic (prominent delusions, hallucinations and commensurate behavioural disturbance) I would statistically expect a poor level of insight. I see this in actual practice ‘all the time’. Poor or absent levels of insight - to the extent that it is a source of behavioural disturbance, poor compliance and behavioural disturbance - becomes part of both nature and degree of illness.
The law or others may tell me ‘no you’re confused’ which is fine because they can - but it would not change the facts. Pi remains less than 2.0.
Many people ‘up and down this country’ for years have taken ‘ex parte Smith’ as a definitive ruling on the meaning of nature and degree as legal concepts. [Sidebar: recall global riots of years ago about ‘The Satanic Verses’ which most rioters actually never read.] Many have not actually studied the ex parte Smith judgment. When they do they will find the following.
Smith v MHRT did not establish a binding legal definition of “nature” or “degree.” It endorsed a tribunal’s reasoning within the limits of judicial review, but left the conceptual boundaries of these terms unresolved. The widespread professional reliance on the judgment as a definitional authority reflects a misreading that conflates clinical shorthand with legal interpretation.
But because everybody disagrees with me, I am wrong and insightless!
I think insight is equally as relevant to nature as it is degree in almost every case i’ve ever come across.
Your insight into pi is partial but I think I agree with you on the sometimes overly-rigid delineation between nature and degree.
OMG! 
That’s a shocking an unexpected compliment I will take it as, even if unintended to be a compliment.
Unfortunately, your website and you do not tolerate dissertations. So I could not demonstrate greater insight on Pi. My bad.
The ‘over-rigid’ delineation between nature and degree is based on a post-truth as delineated by Lee McIntyre. My insight on that will appear partial; limited by word count.
No there’s been a misunderstanding within my words.
I am aware the patient has had a tribunal and you are considering an appeal.
I was pointing out that the word ‘insight’ serves almost like a deterrent for anyone considering appealing a decision. Which I feel is what the MHT are trying to do here.
Because based on what you have written. They say the patient has no mental health disorder - yet, they are now suddenly saying ‘they lack insight’. These are two different aspects. If they are saying the patient is not with a disorder then on what grounds is them having no insight valid to keep them in detention - even more so as a symptom? It’s not.
Psychological symptoms are to do with what someone sees within a person. E.g. changes in behaviour etc or change in feeling.
To me - lacking insight into your condition (DIP) is not an observed presentation.
It’s ambiguous. How many persons with mental health when asked about their symptoms say to their psychiatrist? ‘My partner has seen me walk around too much - on occasion I feel down in the dumps, my mood is also up and down - oh yeah - I also lack insight into all of this’.
You have a list of genuine psychological symptoms and then suddenly you have something that does not fit the pattern. Insight in this context is a state of awareness into something - not something that is observed from a standpoint by someone else.
I was trying to encourage you as their representative to push for an appeal as you have a clear case to - as ‘lack of insight’ is not a symptom - they are just moving the goal posts in my view as there is nothing else to keep the patient in detention.
Also my suggestions were to do with the appeal you may put forward to counter the MHT view surrounding ‘lack of insight’. However, I am not sure of the process surrounding a lawyer appealing a MHT decision and what you have to do within it.
Appreciate your reply to me. Thanks.
I don’t wish to butt in on a private conversation between two people on this forum.
However, conversation led me to recall from some time ago when I responded to a direct question by a patient (P): “Do I look like I have a mental illness - I have no symptoms or signs of illness. There is no evidence that I’ve been hallucinated or deluded for weeks or months!”
My response: “You are suffering with a mental disorder of a nature or degree that requires continued detention in a hospital for appropriate treatment.”
Then P insensed by my dispassionate response goes, “SUFFERING?! I’m not suffering with anyhthing. I’m not distressed. I’m sleeping well, eating well and attending activities. No signs or symptoms of psychosis - you know this!!”
I then tried to explain why I was using the word ‘suffering’ and its source in law. But that made no difference. My every attempt to explain was cut up by rapid fire pressured speech. So as to avoid being accused by dumb people around me, of causing a patient distress - and being sent to the GMC, I politely wound down the conversation. [Some are unaware of what’s happening at the coalface of psychiatry. I require no opinion on who gets sent to the GMC - as I will respond and then head off topic.]
It is unlikely from my long experience that a decision-making body with statutory authority, contemplating detention or discharge, would focus on single symptoms or signs or the absence of signs and symptoms.
The absence of signs or symptoms does not mean a person is not ‘suffering’ with a mental disorder. Hence I know of symptom-free and signs-free patients who have been lawfully detained under Mental Health Act 1983 (Amended 2007) in High Security for years.
I am unable to demonstrate full insight (due to word count limits).
I think the conversation shows the divide between lawyers and psychiatrists. As a lawyer my remit is to try and narrowly interpret ‘nature and degree’ in accordance with the case law in Smith in order to obtain discharge for the client. This may be a helpful legal fiction but, as someone who is not medically trained, it makes sense to me. You should not be detained if you are not showing any symptoms by the time of the tribunal( Degree) UNLESS you are likely to relapse and show them again if discharged ( Nature.) It makes no sense to me to use lack of insight as part of degree as it is not a symptom of mental disorder per se . Some people never gain insight but that is the nature of their disorder. To go back to my original case-the patient had a transient drug induced psychosis which had resolved and which would not recur if he stopped taking illicits -which he said he would. I was arguing that he should not be detained simply because he did not accept that he had suffered a DIP. I still think that is correct. Patient has been discharged so I will not be appealing anyway. Thank you all for the interesting views.
I apologise for my typing speed exceeding 100wpm and words flying from my finger tips almost at the speed I can speak them.
I studied all of your post carefully. Some observations first. Your starting line is analogous to psychiatrists who regularly go ‘I’m not a lawyer’ and then ‘my remit is caring for patients’.
In the words of the most hated former speaker of the House, Bercow, I’m not interested in flying flamingos. 
Logic prevails above all medical and legal reasoning. We can head back to Bolam and Bolitho to revisit that, if needed.
A bloke some 400 years ago, lay in a bed for most of 40 years of his life and created the mind-body dualism that was to infect nearly all of legal and medical systems.
Enter exparte Smith which was taken as separating and defining ‘nature’ and ‘degree’ when it didn’t and ‘infected’ minds and thinking.
Hence Thomas Cardinal Wolsey was right to say, “Be very, very careful what you put in that head , because you will never, ever get it out.”
The Mental Health Act 1983 (Amended 2007) like it or lump it - because Parliament is supreme - is clear on the issues surrounding detention criteria and ‘likely to relapse’ is not in the wording.
It makes perfect sense to me not because I am a psychiatrist, based on my previous explanatons; driven by logic - not medical authority, not legal precedent. To recap it depends on whether lack of insight sits partly in ‘nature’ and partly in ‘degree’ depending the overall characteristics of the patient’s mental disorder.
Totally correct.
I do not know the case and not interested in specifics as this is in the public domain. DIP is hardly ever properly diagnosed from my experience over the last 30 years. So I am ‘statistically biased’ in my views due to poor practice I see ‘out there’. All DIPs should be transient simple because logically they cannot persist outside of continued mind-altering substance misuse.
However, the confusion arises in a blur between what is a transient DIP and something else that merges into a psychosis such as schizophrenia. Some may have forgotten the case of Clunis from around 1991-ish and repeats of the same confusions in several other inquiries. Lessons learned? Nope! Psychiatrists do as they please because ‘we are doctors’.
All I can say is that in 30-odd years of experience I have come across maybe two pure DIPs. I must have been working on all the wrong places.
For the most part many DIPs merge and blend into schizophrenia in the settings I’ve worked in.
The linear idea that ‘people’ will not become psyhotic again because they say ‘I’ll never use drugs again’ is just that - it’s easy. Most people I’ve met with a DIP will have had some form of dependence or serious habituation to mind-altering substances to cause their DIPs. Let’s call that addiction to for the moment - a concept well defined by the Edwards clinical criteria. Reinstatement after abstinence is the big one.
If the statement of reasons was that clear, you can and should challenge it. Pro bono.
DIP is a mental disorder for the purposes of the MHA. [But not everybody believes that].
I’ve seen patients locked up for schizophrenia - for years - because they simply refuse to accept they suffered with schizophrenia. In those scenarios the lack of insight was both ‘nature’ and ‘degree’. In other words ‘you (meaning the patient) can’t demonstrate such a lack of insight, refuse to do offence related work and simple argue that you ought to be let out now.’
Why did they put it as ‘degree’ instead of ‘nature’?
The MHT accepted the RA’s case that Nature was not present but felt degree was satisfied because of lack of insight.
I will have a look at Russell’s thought provoking post later with a glass of wine …
What did the RA say that convinced the MHT that ‘lack of insight’ was categorised as a degree instead of nature? What was their argument?
Why did the RA represent it as a degree and not nature?
If MHT are familiar with nature and degree legal principles - they why did they accept something that did not meet the criteria for degree?